Anat Cell Biol.  2024 Dec;57(4):503-510. 10.5115/acb.24.065.

Localizing motor entry points of adductor muscles of thigh for motor point procedures in the treatment of adductor spasticity

• Albert AM
• Magimairaj HP
• Lakshmanan J
• Holla SJ
• Prithishkumar IJ

• KMID: 2562497
• DOI: http://doi.org/10.5115/acb.24.065

Abstract

Spasticity which is focal or segmental such as affecting a single muscle group or limb can be treated by chemical neurolysis or surgical denervation at the neurovascular hilus. This study determines the motor entry points (MEPs) of adductor muscles of the thigh in the adult Indian population and identifies precise anatomical landmarks for the successful performance motor point procedures for the relief of muscle spasticity. A total of 10 adult lower limbs were dissected, and nerve branches to adductor muscles were carefully exposed up to their MEP. The morphometry of adductor muscles, precise locations of proximal and distal MEPs, and ideal sites for motor point procedures were identified. The median number of MEPs in adductor longus was two. Most of them were located between 40% and 50% of the muscle length i.e., in the thirdfifth of the total muscle length. Adductor magnus and gracilis had a median number of one and six MEPs respectively. The ideal site of motor point procedures is in the second-fifth of the muscle length for both. This preliminary study describes the location of MEPs and ideal sites of motor point procedures in the adductor muscle of the thigh. However, further cadaveric and electromyographic studies with larger samples are necessary to investigate precise locations of MEPs aiding in the treatment of spasticity.

Keyword

Motor end plate; Muscle spasticity; Botulinum toxin; Lower limb

Figure

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  Fig. 1 Representative diagram showing three motor entry points in a muscle. The proximal entry point (PEP) and distal entry point (DEP) are labelled. Region between the PEP and DEP is the ideal site for motor point procedures.

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  Fig. 2 Shows the ideal site for motor point procedures in the adductor muscles based on the current study (A) adductor longus (B) adductor magnus (C) gracilis. PEP, proximal entry point; DEP, distal entry point.

Reference

References

1. Bhimani R, Anderson L. 2014; Clinical understanding of spasticity: implications for practice. Rehabil Res Pract. 2014:279175. DOI: 10.1155/2014/279175. PMID: 25276432. PMCID: PMC4168242.

2. Won SY, Rha DW, Kim HS, Jung SH, Park ES, Hu KS, Kim HJ. 2012; Intramuscular nerve distribution pattern of the adductor longus and gracilis muscles demonstrated with Sihler staining: guidance for botulinum toxin injection. Muscle Nerve. 46:80–5. DOI: 10.1002/mus.23273. PMID: 22644785.

3. Hwang K, Lee KM, Han SH, Kim SG. 2010; Shape and innervation of popliteus muscle. Anat Cell Biol. 43:165–8. DOI: 10.5115/acb.2010.43.2.165. PMID: 21189998. PMCID: PMC2998787.

4. Thompson AJ, Jarrett L, Lockley L, Marsden J, Stevenson VL. 2005; Clinical management of spasticity. J Neurol Neurosurg Psychiatry. 76:459–63. DOI: 10.1136/jnnp.2004.035972. PMID: 15774425. PMCID: PMC1739594.

5. Albert AM, Holla SJ, M HP, Prithishkumar IJ. 2019; Anatomical localization of motor entry points of hamstring muscles - for neurolysis in hamstring spasticity. Int J Anat Res. 7:7176–82. DOI: 10.16965/ijar.2019.336.

6. Frontera WR, Delisa JA, Gans BM, Walsh NE, Robinson LR. Delisa's physical medicine and rehabilitation: principles and practice. 5th ed. Lippincott Williams & Wilkins;2010. p. 1319–37.

7. Ghai A, Garg N, Hooda S, Gupta T. 2013; Spasticity - pathogenesis, prevention and treatment strategies. Saudi J Anaesth. 7:453–60. DOI: 10.4103/1658-354X.121087. PMID: 24348300. PMCID: PMC3858699.

8. Gao ZY, Li L, Song JF, Chen W, Ma P, Wu JX. 2022; Location of motor branches of tibialis posterior muscle and its relation in treatment of spastic equinovarus foot: a cadaveric study. Braz J Anesthesiol. 72:286–90. DOI: 10.1016/j.bjane.2021.04.007. PMID: 33915194. PMCID: PMC9373678.

9. Verrotti A, Greco R, Spalice A, Chiarelli F, Iannetti P. 2006; Pharmacotherapy of spasticity in children with cerebral palsy. Pediatr Neurol. 34:1–6. DOI: 10.1016/j.pediatrneurol.2005.05.001. PMID: 16376270.

10. Lee JH, Lee BN, An X, Chung RH, Han SH. 2011; Location of the motor entry point and intramuscular motor point of the tibialis posterior muscle: for effective motor point block. Clin Anat. 24:91–6. DOI: 10.1002/ca.21062. PMID: 21154644.

11. Morrison JE, Hertzberg DL, Gourley SM, Matthews DJ. 1989; Motor point blocks in children. A technique to relieve spasticity using phenol injections. AORN J. 49:1346–7. 1349–51. 1354DOI: 10.1016/S0001-2092(07)70112-6. PMID: 2658800.

12. Copp EP, Harris R, Keenan J. 1970; Peripheral nerve block and motor point block with phenol in the management of spasticity. Proc R Soc Med. 63:937–8. DOI: 10.1177/003591577006300932.

13. Ruiz FJ, Guest JF, Lehmann A, Davie AM, Güttler K, Schlüter O, Dreiss G. 2004; Costs and consequences of botulinum toxin type A use. Management of children with cerebral palsy in Germany. Eur J Health Econ. 5:227–35. DOI: 10.1007/s10198-004-0224-7. PMID: 15714343.

14. Dursun N, Dursun E, Alican D. 2002; The role of botulinum toxin a in the management of lower limb spasticity in patients with cerebral palsy. Int J Clin Pract. 56:564–7. DOI: 10.1111/j.1742-1241.2002.tb11324.x. PMID: 12425363.

15. Kuo CL, Hu GC. 2018; Post-stroke spasticity: a review of epidemiology, pathophysiology, and treatments. Int J Gerontol. 12:280–4. DOI: 10.1016/j.ijge.2018.05.005.

16. Jankovic J, Brin MF. 1991; Therapeutic uses of botulinum toxin. N Engl J Med. 324:1186–94. DOI: 10.1056/NEJM199104253241707. PMID: 2011163.

17. Yi KH, Lee JH, Kim HJ. 2022; Intramuscular neural distribution of the serratus anterior muscle: regarding botulinum neurotoxin injection for treating myofascial pain syndrome. Toxins (Basel). 14:271. DOI: 10.3390/toxins14040271. PMID: 35448880. PMCID: PMC9033065.

18. Childers MK. 2004; Targeting the neuromuscular junction in skeletal muscles. Am J Phys Med Rehabil. 83(10 Suppl):S38–44. DOI: 10.1097/01.PHM.0000141129.23219.42. PMID: 15448576.

19. Yi KH, Lee JH, Hur HW, Lee HJ, Choi YJ, Kim HJ. 2023; Distribution of the intramuscular innervation of the triceps brachii: clinical importance in the treatment of spasticity with botulinum neurotoxin. Clin Anat. 36:964–70. DOI: 10.1002/ca.24004. PMID: 36606364.

20. An XC, Lee JH, Im S, Lee MS, Hwang K, Kim HW, Han SH. 2010; Anatomic localization of motor entry points and intramuscular nerve endings in the hamstring muscles. Surg Radiol Anat. 32:529–37. DOI: 10.1007/s00276-009-0609-5. PMID: 20063163.

21. Bretonnier M, Lemée JM, Berton JE, Morandi X, Haegelen C. 2019; Selective neurotomy of the sciatic nerve branches to the hamstring muscles: an anatomical study. Orthop Traumatol Surg Res. 105:1413–8. DOI: 10.1016/j.otsr.2019.07.019. PMID: 31588035.

22. Phadke CP, Balasubramanian CK, Holz A, Davidson C, Ismail F, Boulias C. 2016; Adverse clinical effects of botulinum toxin intramuscular injections for spasticity. Can J Neurol Sci. 43:298–310. DOI: 10.1017/cjn.2015.314. PMID: 26597813.

23. Wee SY, Park ES. 2022; Immunogenicity of botulinum toxin. Arch Plast Surg. 49:12–8. DOI: 10.5999/aps.2021.00766. PMID: 35086302. PMCID: PMC8795657.

24. Dressler D. 2004; Clinical presentation and management of antibody-induced failure of botulinum toxin therapy. Mov Disord. 19(Suppl 8):S92–100. DOI: 10.1002/mds.20022. PMID: 15027060.

25. Van Campenhout A, Bar-On L, Desloovere K, Huenaerts C, Molenaers G. 2015; Motor endplate-targeted botulinum toxin injections of the gracilis muscle in children with cerebral palsy. Dev Med Child Neurol. 57:476–83. DOI: 10.1111/dmcn.12667. PMID: 25557985.

26. Puligopu AK, Purohit AK. 2011; Outcome of selective motor fasciculotomy in the treatment of upper limb spasticity. J Pediatr Neurosci. 6(Suppl 1):S118–25. DOI: 10.4103/1817-1745.85730. PMID: 22069422. PMCID: PMC3208924.

27. Maarrawi J, Mertens P, Luaute J, Vial C, Chardonnet N, Cosson M, Sindou M. 2006; Long-term functional results of selective peripheral neurotomy for the treatment of spastic upper limb: prospective study in 31 patients. J Neurosurg. 104:215–25. DOI: 10.3171/jns.2006.104.2.215. PMID: 16509495.

28. Decq P, Filipetti P, Cubillos A, Slavov V, Lefaucheur JP, Nguyen JP. 2000; Soleus neurotomy for treatment of the spastic equinus foot. Groupe d'Evaluation et de Traitement de la Spasticité et de la Dystonie. Neurosurgery. 47:1154–60. discussion 1160–1. DOI: 10.1097/00006123-200011000-00027. PMID: 11063109.

29. Sindou MP, Simon F, Mertens P, Decq P. 2007; Selective peripheral neurotomy (SPN) for spasticity in childhood. Childs Nerv Syst. 23:957–70. DOI: 10.1007/s00381-007-0399-1. PMID: 17605016.

30. Shin KJ, Yoo JY, Lee JY, Gil YC, Kim JN, Koh KS, Song WC. 2015; Anatomical study of the nerve regeneration after selective neurectomy in the rabbit: clinical application for esthetic calf reduction. Anat Cell Biol. 48:268–74. DOI: 10.5115/acb.2015.48.4.268. PMID: 26770878. PMCID: PMC4701701.

31. Woodley SJ, Mercer SR. 2005; Hamstring muscles: architecture and innervation. Cells Tissues Organs. 179:125–41. DOI: 10.1159/000085004. PMID: 15947463.

32. Kwon JY, Kim JS, Lee WI. 2009; Anatomic localization of motor points of hip adductors. Am J Phys Med Rehabil. 88:336–41. DOI: 10.1097/PHM.0b013e3181619435. PMID: 18174845.

33. Braddom R. Physical medicine & rehabilitation. Saunders;1996.

34. Borodic GE, Ferrante R, Pearce LB, Smith K. 1994; Histologic assessment of dose-related diffusion and muscle fiber response after therapeutic botulinum A toxin injections. Mov Disord. 9:31–9. DOI: 10.1002/mds.870090106. PMID: 8139603.

35. Van Campenhout A, Molenaers G. 2011; Localization of the motor endplate zone in human skeletal muscles of the lower limb: anatomical guidelines for injection with botulinum toxin. Dev Med Child Neurol. 53:108–19. DOI: 10.1111/j.1469-8749.2010.03816.x. PMID: 20964675.

36. Yi KH, Lee JH, Lee DK, Hu HW, Seo KK, Kim HJ. 2021; Anatomical locations of the motor endplates of sartorius muscle for botulinum toxin injections in treatment of muscle spasticity. Surg Radiol Anat. 43:2025–30. DOI: 10.1007/s00276-021-02813-7. PMID: 34378107. PMCID: PMC8354843.

37. Reddy S, Puligopu AK, Purohit AK. 2015; Results of selective motor fasciculotomy in spastic upper limbs due to cerebral palsy (a review of 30 children and adults). Indian J Cereb Palsy. 1:7–11. DOI: 10.4103/2395-4264.153559.

38. Crystal R, Malone AA, Eastwood DM. Motor points for neuromuscular blockade of the adductor muscle group. Clin Orthop Relat Res. 2005; (437):196–200. DOI: 10.1097/01.blo.0000165856.38166.9a. PMID: 16056049.

39. Fheodoroff K, Schurch B, Heck G. Pocket atlas treatment of spasticity with botulinum A toxin, volume 2. Saentis;2005.

40. Berweck S, Heinen F. Treatment of cerebral palsy with botulinum toxin: principles, clinical practice, atlas. Child & Brain;2003.